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Möckel M. The new ESC acute coronary syndrome guideline and its impact in the CPU and emergency department setting. Herz 2024; 49:185-189. [PMID: 38467788 DOI: 10.1007/s00059-024-05241-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/13/2024]
Abstract
The new guideline on acute coronary syndrome (ACS) of the European Society of Cardiology (ESC) replaces two separate guidelines on ST-elevation myocardial infarction (STEMI) and non-ST-elevation (NSTE) ACS. This change of paradigm reflects the experts view that the ACS is a continuum, starting with unstable angina and ending in cardiogenic shock or cardiac arrest due to severe myocardial ischemia. Secondary, partly non-atherosclerotic-caused myocardial infarctions ("type 2") are not integrated in this concept.With respect to acute care in the setting of emergency medicine and the chest pain unit structures, the following new aspects have to be taken into account:1. New procedural approach as "think A.C.S." meaning "abnormal ECG," "clinical context," and "stable patient"2. New recommendation regarding a holistic approach for frail patients3. Revised recommendations regarding imaging and timing of invasive strategy in suspected NSTE-ACS4. Revised recommendations for antiplatelet and anticoagulant therapy in STEMI5. Revised recommendations for cardiac arrest and out-of-hospital cardiac arrest6. Revised recommendations for in-hospital management (starting in the CPU/ED) and ACS comorbid conditionsIn summary, the changes are mostly gradual and are not based on extensive new evidence, but more on focused and healthcare process-related considerations.
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Affiliation(s)
- Martin Möckel
- Notfall- und Akutmedizin mit Chest Pain Units, Charité-Universitätsmedizin Berlin, Campus Mitte und Virchow-Klinikum, Charitéplatz 1, 10117, Berlin, Germany.
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2
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Fernández-Cisnal A, Lopez-Ayala P, Valero E, Koechlin L, Catarralá A, Boeddinghaus J, Noceda J, Nestelberger T, Miró Ò, Julio N, Mueller C, Sanchis J. Derivation and external validation of machine-learning models for risk stratification in chest pain with normal troponin. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:743-752. [PMID: 37531633 DOI: 10.1093/ehjacc/zuad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
AIMS Risk stratification of patients with chest pain and a high-sensitivity cardiac troponin T (hs-cTnT) concentration METHODS AND RESULTS Four machine-learning-based models and one logistic regression (LR) model were trained on 4075 patients (single-centre Spanish cohort) and externally validated on 3609 patients (international prospective Advantageous Predictors of Acute Coronary syndromes Evaluation cohort). Models were compared with GRACE and HEART scores and a single undetectable hs-cTnT-based strategy (u-cTn; hs-cTnT < 5 ng/L and time from symptoms onset >180 min). Probability thresholds for safe discharge were derived in the derivation cohort. The endpoint occurred in 105 (2.6%) patients in the training set and 98 (2.7%) in the external validation set. Gradient boosting full (GBf) showed the best discrimination (area under the curve = 0.808). Calibration was good for the reduced neural network and LR models. Gradient boosting full identified the highest proportion of patients for safe discharge (36.7 vs. 23.4 vs. 27.2%; GBf vs. LR vs. u-cTn, respectively) with similar safety (missed endpoint per 1000 patients: 2.2 vs. 3.5 vs. 3.1, respectively). All derived models were superior to the HEART and GRACE scores (P < 0.001). CONCLUSION Machine-learning and LR prediction models were superior to the HEART, GRACE, and u-cTn for risk stratification of patients with chest pain and a baseline hs-cTnT CLINICAL TRIAL REGISTRATION ClinicalTrials.gov number, NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.
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Affiliation(s)
- Agustín Fernández-Cisnal
- Cardiology Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), València, Spain
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ernesto Valero
- Cardiology Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), València, Spain
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arturo Catarralá
- Clinical Biochemistry Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), València 46010, Spain
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - José Noceda
- Emergency Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), València 46010, Spain
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Òscar Miró
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Núñez Julio
- Cardiology Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), València, Spain
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Heart Center Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario de València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), València, Spain
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3
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Mehta P, McDonald S, Hirani R, Good D, Diercks D. Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis. Acad Emerg Med 2022; 29:748-764. [PMID: 34741781 DOI: 10.1111/acem.14407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low- to intermediate-risk patients. METHODS Initially, 952 articles were identified for screening, 81 met criteria for full-text review, and once risk of bias was assessed, 33 articles were included in this meta-analysis. We utilized a random-effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low- to intermediate-risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q-test and I2 statistic. RESULTS Twenty-one studies evaluated follow-up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within-group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). CONCLUSIONS Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.
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Affiliation(s)
- Prayag Mehta
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Raiz Hirani
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel Good
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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4
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Meek R, Cullen L, Lu ZX, Nasis A, Kuhn L, Sorace L. Potential impact of a novel pathway for suspected myocardial infarction utilising a new high-sensitivity cardiac troponin I assay. Emerg Med J 2021; 39:847-852. [PMID: 34759013 DOI: 10.1136/emermed-2020-210812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/27/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin I (hs-cTnI) assays promise high diagnostic accuracy for myocardial infarction (MI). In an ED where conventional cTnI was in use, we evaluated an assessment pathway using the new Access hsTnI assay. METHODS This retrospective analysis recruited ED patients with suspected MI between June and September 2019. All patients received routine care with a conventional cTnI assay (AccuTnI +3: limit of detection (LoD) 10 ng/L, 99th centile upper reference limit (URL) 40 ng/L, abnormal elevation cut-point 80 ng/L). Arrival, then 90-minute or 360-minute cTnI levels for low and non-low risk patients, respectively (ED Assessment of Chest pain score) guided diagnosis and disposition which was at treating physician discretion. The same patients had arrival and 90-minute or 180-minute samples drawn for hs-cTnI levels (Access hsTnI: LoD 2 ng/L, 99th centile URL 10 ng/L (females) and 20 ng/L (males); abnormal elevation above the URL and delta >30%). Treating physicians were blinded to the hs-cTnI results. Using the hs-cTnI values, investigators retrospectively assigned likely diagnosis, disposition and likelihood of a 30-day major adverse cardiac event (MACE). Admission was recommended for significantly rising hs-cTnI elevations. The primary objective was to demonstrate an acceptable unexpected 30-day post-discharge MACE rate of <1%. cTnI elevation rates, diagnostic outcomes and ED disposition were also compared between pathways. RESULTS For the 935 patients, unexpected 30-day post-discharge MACE rates were 0/935 (0%, 95% CI 0% to 0.4%) with the conventional or novel pathway. For the high-sensitivity and conventional assays, respectively, abnormal elevation rates were 29% (95% CI 26% to 32%) and 19% (95% CI 17% to 22%), for MI were 9% (95% CI 8% to 11%) and 8% (95% CI 6% to 10%), and for hospital admission were 42% (95% CI 39% to 45%) and 43% (95% CI 40% to 47%). CONCLUSION The novel pathway using the Access hsTnI assay has an acceptably low 30-day MACE rate.
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Affiliation(s)
- Rob Meek
- Emergency Department, Monash Health, Melbourne, Victoria, Australia .,Medicine, Monash University, Melbourne, Victoria, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Zhong Xian Lu
- Emergency Department, Monash Health, Melbourne, Victoria, Australia.,Medicine, Monash University, Melbourne, Victoria, Australia
| | - Arthur Nasis
- Emergency Department, Monash Health, Melbourne, Victoria, Australia.,Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lisa Kuhn
- Emergency Department, Monash Health, Melbourne, Victoria, Australia.,Medicine, Monash University, Melbourne, Victoria, Australia
| | - Laurence Sorace
- Melbourne Medical School, The University of Melbourne - Parkville Campus, Melbourne, Victoria, Australia.,Medicine, Northern Health, Melbourne, Victoria, Australia
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5
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Giannitsis E, Blankenberg S, Christenson RH, Frey N, von Haehling S, Hamm CW, Inoue K, Katus HA, Lee CC, McCord J, Möckel M, Chieh JTW, Tubaro M, Wollert KC, Huber K. Critical appraisal of the 2020 ESC guideline recommendations on diagnosis and risk assessment in patients with suspected non-ST-segment elevation acute coronary syndrome. Clin Res Cardiol 2021; 110:1353-1368. [PMID: 33635437 PMCID: PMC8405476 DOI: 10.1007/s00392-021-01821-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/08/2021] [Indexed: 10/27/2022]
Abstract
Multiple new recommendations have been introduced in the 2020 ESC guidelines for the management of acute coronary syndromes with a focus on diagnosis, prognosis, and management of patients presenting without persistent ST-segment elevation. Most recommendations are supported by high-quality scientific evidence. The guidelines provide solutions to overcome obstacles presumed to complicate a convenient interpretation of troponin results such as age-, or sex-specific cutoffs, and to give practical advice to overcome delays of laboratory reporting. However, in some areas, scientific support is less well documented or even missing, and other areas are covered rather by expert opinion or subjective recommendations. We aim to provide a critical appraisal on several recommendations, mainly related to the diagnostic and prognostic assessment, highlighting the discrepancies between Guideline recommendations and the existing scientific evidence.
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Affiliation(s)
- Evangelos Giannitsis
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
| | | | - Norbert Frey
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Kenji Inoue
- Department of Cardiovascular Biology and Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hugo A Katus
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - James McCord
- Henry Ford Heart and Vascular Institute Detroit, Detroit, MI, USA
| | - Martin Möckel
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte and Virchow, Berlin, Germany
| | - Jack Tan Wei Chieh
- Department of Cardiology, National Heart Centre and Sengkang General Hospital, Singapore, Singapore
| | | | - Kai C Wollert
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria.,Medical School, Sigmund Freud University, Vienna, Austria
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6
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Weber B, He Z, Yang N, Playford MP, Weisenfeld D, Iannaccone C, Coblyn J, Weinblatt M, Shadick N, Di Carli M, Mehta NN, Plutzky J, Liao KP. Divergence of Cardiovascular Biomarkers of Lipids and Subclinical Myocardial Injury Among Rheumatoid Arthritis Patients With Increased Inflammation. Arthritis Rheumatol 2021; 73:970-979. [PMID: 33615723 DOI: 10.1002/art.41613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/03/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) are 1.5 times more likely to develop cardiovascular disease (CVD) attributed to chronic inflammation. A decrease in inflammation in patients with RA is associated with increased low-density lipoprotein (LDL) cholesterol. This study was undertaken to prospectively evaluate the changes in lipid levels among RA patients experiencing changes in inflammation and determine the association with concomitant temporal patterns in markers of myocardial injury. METHODS A total of 196 patients were evaluated in a longitudinal RA cohort, with blood samples and high-sensitivity C-reactive protein (hsCRP) levels measured annually. Patients were stratified based on whether they experienced either a significant increase in inflammation (an increase in hsCRP of ≥10 mg/liter between any 2 time points 1 year apart; designated the increased inflammation cohort [n = 103]) or decrease in inflammation (a decrease in hsCRP of ≥10 mg/liter between any 2 time points 1 year apart; designated the decreased inflammation cohort [n = 93]). Routine and advanced lipids, markers of inflammation (interleukin-6, hsCRP, soluble tumor necrosis factor receptor II), and markers of subclinical myocardial injury (high-sensitivity cardiac troponin T [hs-cTnT], N-terminal pro-brain natriuretic peptide) were measured. RESULTS Among the patients in the increased inflammation cohort, the mean age was 59 years, 81% were women, and the mean RA disease duration was 17.9 years. The average increase in hsCRP levels was 36 mg/liter, and this increase was associated with significant reductions in LDL cholesterol, triglycerides, total cholesterol, apolipoprotein (Apo B), and Apo A-I levels. In the increased inflammation cohort at baseline, 45.6% of patients (47 of 103) had detectable circulating hs-cTnT, which further increased during inflammation (P = 0.02). In the decreased inflammation cohort, hs-cTnT levels remained stable despite a reduction in inflammation over follow-up. In both cohorts, hs-cTnT levels were associated with the overall estimated risk of CVD. CONCLUSION Among RA patients who experienced an increase in inflammation, a significant decrease in routinely measured lipids, including LDL cholesterol, and an increase in markers of subclinical myocardial injury were observed. These findings highlight the divergence in biomarkers of CVD risk and suggest a role in future studies examining the benefit of including hs-cTnT for CVD risk stratification in RA.
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Affiliation(s)
- Brittany Weber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Zeling He
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nicole Yang
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Dana Weisenfeld
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Jonathan Coblyn
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael Weinblatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nancy Shadick
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marcelo Di Carli
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nehal N Mehta
- National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland
| | - Jorge Plutzky
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Katherine P Liao
- Brigham and Women's Hospital, Harvard Medical School, and VA Boston Healthcare System, Boston, Massachusetts
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7
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Prognostic value of copeptin in patients with acute coronary syndrome: A systematic review and meta-analysis. PLoS One 2020; 15:e0238288. [PMID: 32857795 PMCID: PMC7454979 DOI: 10.1371/journal.pone.0238288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/11/2020] [Indexed: 12/31/2022] Open
Abstract
Background The aim of this study was to evaluate the value of copeptin in predicting mortality including both short-term and long-term mortality in patients with acute coronary syndrome (ACS). Methods Potential studies were searched and selected through PubMed, Embase and Cochrane databases up to December 2019. The predictive performance was evaluated by the pooled sensitivity and specificity, and summary receiver operating characteristic curves. Cochran’s Q test and I2 index were used to assess between-study heterogeneity, and Deek’s test and funnel plots were used to assess publication bias. Results Total six studies comprising 2269 patients were included in this meta-analysis. The area under the receiver operating characteristic curve of copeptin in predicting mortality in patients with ACS was 0.73 (95% CI: 0.69–0.77). The pooled sensitivity and specificity of copeptin were 0.77 (95% CI: 0.59–0.89) and 0.60 (95% CI: 0.47–0.71), respectively. Significant between-study heterogeneity was identified in both sensitivity (P = 0.01; I2 = 69.76%) and specificity (P<0.001; I2 = 97.32%) among the six included studies. The meta-regression analysis indicated that the number of study centers was significantly associated with the heterogeneity of sensitivity (P = 0.03), whereas the study design (P = 0.03) and duration of follow-up (P<0.001) were significantly associated with the heterogeneity of specificity. Conclusions Copeptin has acceptable prognostic value for mortality in patients with ACS. Further studies based on multimarker strategy are needed to evaluate the prognostic value of copeptin for ACS in conjunction with other well-established biomarkers.
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Sanchis J, Valero E, García Blas S, Barba E, Pernias V, Miñana G, Brasó J, Fernandez-Cisnal A, Gonzalez J, Noceda J, Carratalá A, Chorro FJ, Núñez J, Pickering JW. Undetectable high-sensitivity troponin in combination with clinical assessment for risk stratification of patients with chest pain and normal troponin at hospital arrival. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:567-575. [PMID: 32067483 DOI: 10.1177/2048872620907539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Undetectable high-sensitivity cardiac troponin (hs-cTn) in a single determination upon admission may rule out acute coronary syndrome. We investigated undetectable hs-cTnT (<detection limit; <5 ng/l) together with clinical risk scores (GRACE, TIMI, HEART and a previously published simple score), for one-year outcomes in patients with chest pain and normal hs-cTnT (<99th percentile; <14 ng/l) upon admission. METHODS This study was a retrospective design involving 2254 consecutive patients (July 2016-November 2017). The primary endpoint was one-year death or acute myocardial infarction; the secondary endpoint added unstable angina requiring revascularization. Early (<90 minutes since pain onset, n = 661) and late (n = 1593) presenters were separately considered. RESULTS A total of 56 (2.5%) patients reached the primary endpoint and 91 (4%) the secondary endpoint. Undetectable hs-cTnT had a poor C-statistic in early and late presenters (0.648 and 0.703, respectively). Adding hs-cTnT measurable concentrations above the detection limit (as continuous variable) significantly enhanced the C-statistics (0.754 and 0.847, respectively). Addition of the HEART (0.809, p = 0.005) or simple clinical scores (0.804, p = 0.02) further improved the model and significantly reclassified patient risk, in early presenters. The results were similar for the secondary endpoint. The TIMI risk score performed worse and the GRACE score did not give additional information. In late presenters, no clinical score provided significant additional information over hs-cTnT. CONCLUSIONS Diagnostic algorithms should consider not only whether hs-cTnT is above or below the detection limit but also its concentration if above, for risk stratification over one year in patients with initial normal hs-cTnT. The clinical scores provide valuable additional information in early presenters.
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Affiliation(s)
- Juan Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - Ernesto Valero
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - Sergio García Blas
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - Esther Barba
- Servei de Bioquímica Clínica, Hospital Clínic Universitari de València, Spain
| | - Vicente Pernias
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - Gema Miñana
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - José Brasó
- Servei d'Urgències Mèdiques, Hospital Clínic Universitari de València, Spain
| | - Agustín Fernandez-Cisnal
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - Jessika Gonzalez
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - José Noceda
- Servei d'Urgències Mèdiques, Hospital Clínic Universitari de València, Spain
| | - Arturo Carratalá
- Servei de Bioquímica Clínica, Hospital Clínic Universitari de València, Spain
| | - Francisco J Chorro
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - Julio Núñez
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, Spain
| | - John W Pickering
- Department of Medicine, University of Otago Christchurch, New Zealand
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9
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Andruchow JE, Boyne T, Innes G, Vatanpour S, Seiden-Long I, Wang D, Lang E, McRae AD. Low High-Sensitivity Troponin Thresholds Identify Low-Risk Patients With Chest Pain Unlikely to Benefit From Further Risk Stratification. CJC Open 2019; 1:289-296. [PMID: 32159123 PMCID: PMC7063640 DOI: 10.1016/j.cjco.2019.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 01/20/2023] Open
Abstract
Background Very low high-sensitivity cardiac troponin T (hs-cTnT) thresholds on presentation can rule out acute myocardial infarction (AMI), but the ability to identify patients at low risk of 30-day major adverse cardiac events (MACE) is less clear. This study examines the sensitivity of low concentrations of hs-cTnT on presentation to rule out 30-day MACE. Methods This prospective cohort study enrolled patients with chest pain presenting to the emergency department with nonischemic electrocardiograms who underwent AMI rule-out with an hs-cTnT assay. The primary outcome was 30-day MACE; secondary outcomes were individual MACE components. Because guidelines recommend using a single hs-cTnT strategy only for patients with more than 3 hours since symptom onset, a subgroup analysis was performed for this population. Outcomes were adjudicated on the basis of review of medical records and telephone follow-up. Results Of 1167 patients enrolled, 125 (10.7%) experienced 30-day MACE and 97 (8.3%) had AMI on the index visit. More than one-third of patients (35.6%) had presenting hs-cTnT concentrations below the limit of detection (5 ng/L), which was 94.4% (95% confidence interval [CI], 88.8-97.7) sensitive for 30-day MACE and 99.0% (95% CI, 94.5-100) sensitive for index AMI. Of 292 patients (25.0%) with hs-cTnT < 5 ng/L and at least 3 hours since symptom onset, only 3 experienced 30-day MACE (sensitivity 97.6%; 95% CI, 93.2-100) and none had AMI within 30 days (sensitivity 100%; 95% CI, 96.3-100). Conclusions Among patients with nonischemic electrocardiograms and > 3 hours since symptom onset, low hs-cTnT thresholds on presentation confer a very low risk of 30-day MACE. In the absence of a high-risk clinical presentation, further risk stratification is likely to be low yield.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Timothy Boyne
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Grant Innes
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Isolde Seiden-Long
- Department of Pathology and Laboratory Medicine, University of Calgary and Alberta Public Laboratories, Calgary, Alberta, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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10
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Giannitsis E, Clifford P, Slagman A, Ruedelstein R, Liebetrau C, Hamm C, Honnart D, Huber K, Vollert JO, Simonelli C, Schröder M, Wiemer JC, Mueller-Hennessen M, Schroer H, Kastner K, Möckel M. Multicentre cross-sectional observational registry to monitor the safety of early discharge after rule-out of acute myocardial infarction by copeptin and troponin: the Pro-Core registry. BMJ Open 2019; 9:e028311. [PMID: 31340965 PMCID: PMC6661885 DOI: 10.1136/bmjopen-2018-028311] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES There is sparse information on the safety of early primary discharge from the emergency department (ED) after rule-out of myocardial infarction in suspected acute coronary syndrome (ACS). This prospective registry aimed to confirm randomised study results in patients at low-to-intermediate risk, with a broader spectrum of symptoms, across different institutional standards and with a range of local troponin assays including high-sensitivity cTn (hs-cTn), cardiac troponin (cTn) and point-of-care troponin (POC Tn). DESIGN Prospective, multicentre European registry. SETTING 18 emergency departments in nine European countries (Germany, Austria, Switzerland, France, Spain, UK, Turkey, Lithuania and Hungary) PARTICIPANTS: The final study cohort consisted of 2294 patients (57.2% males, median age 57 years) with suspected ACS. INTERVENTIONS Using the new dual markers strategy, 1477 patients were eligible for direct discharge, which was realised in 974 (42.5%) of patients. MAIN OUTCOME MEASURES The primary endpoint was all-cause mortality at 30 days. RESULTS Compared with conventional workup after dual marker measurement, the median length of ED stay was 60 min shorter (228 min, 95% CI: 219 to 239 min vs 288 min, 95% CI: 279 to 300 min) in the primary dual marker strategy (DMS) discharge group. All-cause mortality was 0.1% (95% CI: 0% to 0.6%) in the primary DMS discharge group versus 1.1% (95% CI: 0.6% to 1.8%) in the conventional workup group after dual marker measurement. Conventional workup instead of discharge despite negative DMS biomarkers was observed in 503 patients (21.9%) and associated with higher prevalence of ACS (17.1% vs 0.9%, p<0.001), cardiac diagnoses (55.2% vs 23.5%, p<0.001) and risk factors (p<0.01), but with a similar all-cause mortality of 0.2% (95% CI: 0% to 1.1%) versus primary DMS discharge (p=0.64). CONCLUSIONS Copeptin on top of cardiac troponin supports safe discharge in patients with chest pain or other symptoms suggestive of ACS under routine conditions with the use of a broad spectrum of local standard POC, conventional and high-sensitivity troponin assays. TRIAL REGISTRATION NUMBER NCT02490969.
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Affiliation(s)
| | | | - Anna Slagman
- Department of Emergency Medicine CVK, CCM and Department of Cardiology CVK, Charité Universitiy Medicine, Berlin, Germany
- College of Public Health Medical and Veterinary Sciences, Centre for Chronic Disease Prevention, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Queensland, Australia
| | | | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Partner Site, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | - Christian Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
- Partner Site, German Center for Cardiovascular Research (DZHK), Frankfurt am Main, Germany
| | | | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Jörn Ole Vollert
- Cardiovascular Biomarkers, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Carlo Simonelli
- Cardiovascular Biomarkers, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Malte Schröder
- Cardiology, Krankenhaus Hedwigshohe Berlin, Berlin, Germany
| | - Jan C Wiemer
- Cardiovascular Biomarkers, Thermo Fisher Scientific, Hennigsdorf, Germany
| | | | - Hinrich Schroer
- Internal Medicine and Cardiology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Kim Kastner
- Department of Emergency Medicine CVK, CCM and Department of Cardiology CVK, Charité Universitiy Medicine, Berlin, Germany
| | - Martin Möckel
- Department of Emergency Medicine CVK, CCM and Department of Cardiology CVK, Charité Universitiy Medicine, Berlin, Germany
- College of Public Health Medical and Veterinary Sciences, Centre for Chronic Disease Prevention, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Queensland, Australia
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11
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Möckel M. [Biomarkers in the diagnosis of cardiovascular emergencies : Acute coronary syndrome and differential diagnoses]. Internist (Berl) 2019; 60:564-570. [PMID: 31062038 DOI: 10.1007/s00108-019-0620-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In emergency situations, patients present with symptoms rather than diagnoses. Due to its high prevalence, the acute coronary syndrome (ACS) dominates acute diagnostics as a consequence of its chief complaint chest pain. The challenge for the attending physicians is that only a minor part of patients with chest pain are finally diagnosed with an acute myocardial infarction (AMI) and that other rare but dangerous differential diagnoses have to be kept in mind and-vice versa-severely ill patients with AMI may present with symptoms other than chest pain. Against this background, the initial evaluation of patients requires a process-orientated view beyond the key roles of clinical assessment and biomarkers. The use of cardiac troponin is mandatory for the diagnosis of ACS, but challenging in broader utilization due to the reduced clinical specificity. Further relevant biomarkers are copeptin in combination with cardiac troponin or natriuetic peptides, which help to diagnose relevant cardiac dysfunction in (acute) heart failure. In addition, patients who present with the symptom of a suspected cardiac syncope need the differential diagnosis of an underlying arrhythmia, which may be due to an ACS or reduced left ventricular (LV) function and other causes like pulmonary embolism or structural heart disease (e. g. aortic valve stenosis). This highlights that biomarker-based diagnostics are often crucial to decide after the initial clinical evaluation whether early imaging is needed or early discharge is possible.
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Affiliation(s)
- Martin Möckel
- Notfall- und Akutmedizin mit Chest Pain Units, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Charité Mitte, Augustenburger Platz 1, 13363, Berlin, Deutschland. .,Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Deutschland.
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12
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Narayanan MA, Garcia S. Role of High-sensitivity Cardiac Troponin in Acute Coronary Syndrome. US CARDIOLOGY REVIEW 2019. [DOI: 10.15420/usc.2018.16.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chest pain is one of the most common reasons for an emergency room (ER) visit in the US, with almost 6 million ER visits annually. High-sensitivity cardiac troponin (hscTn) assays have the ability to rapidly rule in or rule out acute coronary syndrome with improved sensitivity, and they are increasingly being used. Though hscTn assays have been approved for use in European, Australian, and Canadian guidelines since 2010, the FDA only approved their use in 2017. There is no consensus on how to compare the results from various hscTn assays. A literature review was performed to analyze the advantages and limitations of using hscTn as a standard biomarker to evaluate patients with suspected ACS in the emergency setting.
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Affiliation(s)
- Mahesh Anantha Narayanan
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Santiago Garcia
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN
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13
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Fladseth K, Kristensen A, Mannsverk J, Trovik T, Schirmer H. Pre-test characteristics of unstable angina patients with obstructive coronary artery disease confirmed by coronary angiography. Open Heart 2018; 5:e000888. [PMID: 30487980 PMCID: PMC6241968 DOI: 10.1136/openhrt-2018-000888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/10/2018] [Accepted: 10/17/2018] [Indexed: 12/25/2022] Open
Abstract
Objective Patients referred for acute coronary angiography (CAG) with unstable angina (UA) have low mortality and low rate of obstructive coronary artery disease (CAD). Better pre-test selection criteria are warranted. We aimed to assess the current guidelines against other clinical variables as predictors of obstructive CAD in patients with UA referred for acute CAG. Methods From 2005 to 2012, all CAGs performed at the University Hospital of North Norway, the sole provider of CAG in the region, were recorded in a registry. We included 979 admissions of UA and retrospectively collected data regarding presenting clinical parameters from patient hospital records. Obstructive CAD was defined as ≥50% stenosis and considered prognostically significant if found in the left main stem, proximal LAD or all three main coronary arteries. Characteristics were analysed by logistic regression analysis. A score was developed using ORs from significant factors in a multivariable model. Results The overall rate of obstructive CAD was 45%, and the rate of prognostically significant CAD was 11%. The risk criteria recommended in American College of Cardiology/American Heart Association and European Society of Cardiology guidelines had an area under the curve (AUC) of 0.58. Adding clinical information increased the AUC to 0.77 (95% CI 0.74 to 0.80). Applying the derived score, we found that 56% (n=546) of patients had a score of <13, which was associated with a negative predictive value of 95% for prognostic significant CAD. Conclusions The current results suggest that CAG may be postponed or cancelled in more than half of patients with UA by improving pre-test selection criteria with the addition of clinical parameters to current guidelines.
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Affiliation(s)
- Kristina Fladseth
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Andreas Kristensen
- Division of Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Jan Mannsverk
- Division of Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Thor Trovik
- Division of Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Henrik Schirmer
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
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14
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Mueller-Hennessen M, Lindahl B, Giannitsis E, Vafaie M, Biener M, Haushofer AC, Seier J, Christ M, Alquézar-Arbé A, deFilippi CR, McCord J, Body R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French JK, Christenson RH, Dinkel C, Katus HA, Mueller C. Combined testing of copeptin and high-sensitivity cardiac troponin T at presentation in comparison to other algorithms for rapid rule-out of acute myocardial infarction. Int J Cardiol 2018; 276:261-267. [PMID: 30404726 DOI: 10.1016/j.ijcard.2018.10.084] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/04/2018] [Accepted: 10/23/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND We aimed to directly compare the diagnostic and prognostic performance of a dual maker strategy (DMS) with combined testing of copeptin and high-sensitivity (hs) cardiac troponin T (cTnT) at time of presentation with other algorithms for rapid rule-out of acute myocardial infarction (AMI). METHODS 922 patients presenting to the emergency department with suspected AMI and available baseline copeptin measurements qualified for the present TRAPID-AMI substudy. Diagnostic measures using the DMS (copeptin <10, <14 or < 20 pmol/L and hs-cTnT≤14 ng/L), the 1 h-algorithm (hs-cTnT<12 ng/L and change <3 ng/L at 1 h), as well as the hs-cTnT limit-of-blank (LoB, <3 ng/L) and -detection (LoD, <5 ng/L) were compared. Outcomes were assessed as combined end-points of death and myocardial re-infarction. RESULTS True-negative rule-out using the DMS could be achieved in 50.9%-62.3% of all patients compared to 35.0%, 45.3% and 64.5% using LoB, LoD or the 1 h-algorithm, respectively. The DMS showed NPVs of 98.1%-98.3% compared to 99.2% for the 1 h-algorithm, 99.4% for the LoB and 99.3% for the LoD. Sensitivities were 93.5%-94.8%, as well as 96.8%, 98.7% and 98.1%, respectively. Addition of clinical low-risk criteria such as a HEART-score ≤ 3 to the DMS resulted in NPVs and sensitivities of 100% with a true-negative rule-out to 33.8%-41.6%. Rates of the combined end-point of death/MI within 30 days ranged between 0.2% and 0.3% for all fast-rule-out protocols. CONCLUSION Depending on the applied copeptin cut-off and addition of clinical low-risk criteria, the DMS might be an alternative to the hs-cTn-only-based algorithms for rapid AMI rule-out with comparable diagnostic measures and outcomes.
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Affiliation(s)
- Matthias Mueller-Hennessen
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Mehrshad Vafaie
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Biener
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Josef Seier
- Central Laboratory, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Community Hospital and Paracelsus Medical University, Nuremberg, Germany
| | | | - Christopher R deFilippi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - James McCord
- Henry Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, MI, United States of America
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, and Manchester University NHS Foundation Trust, United Kingdom
| | - Mauro Panteghini
- Department of Biomedical and Clinical Sciences 'Luigi Sacco', University of Milan Medical School, Milano, Italy
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University, Karolinska Institutet, Stockholm, Sweden
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padua, Italy
| | - Franck Verschuren
- Department of Acute Medicine, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - John K French
- Liverpool Hospital and University of New South Wales, Sydney, Australia
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | | | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Mueller
- Cardiology & Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
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15
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Bardají A, Bonet G, Carrasquer A, González-del Hoyo M, Domínguez F, Sánchez R, Boqué C, Cediel G. Prognostic implications of detectable cardiac troponin I below the 99th percentile in patients admitted to an emergency department without acute coronary syndrome. ACTA ACUST UNITED AC 2018; 56:1954-1961. [DOI: 10.1515/cclm-2017-1140] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/03/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background:
Detectable troponin below the 99th percentile may reflect an underlying cardiac abnormality which might entail prognostic consequences. This study aimed to investigate the prognosis of patients admitted to an emergency department (ED) with detectable troponin below the 99th percentile reference limit who did not present with an acute coronary syndrome (ACS).
Methods:
We analysed the clinical data of all consecutive patients admitted to the ED during the years 2012 and 2013 in whom cardiac troponin was requested by the attending clinician (cTnI Ultra Siemens, Advia Centaur). Patients with troponin below the 99th percentile of the reference population (40 ng/L) and who did not have a diagnosis of ACS were selected, and their mortality was evaluated in a 2-year follow-up.
Results:
A total of 2501 patients had a troponin level below the reference limit, with 43.9% of those showing detectable levels (>6 ng/L and <40 ng/L). Patients with detectable levels were elderly and had a higher prevalence of cardiovascular history and more comorbidities. The total mortality in the 2-year follow-up was 12.4% in patients with detectable troponin and 4.5% in patients with undetectable troponin (p<0.001). In the Cox multivariate regression analysis, the detectable troponin was an independent marker of mortality at 2 years (HR 1.62, 95% CI 1.07–2.45, p=0.021).
Conclusions:
Detectable troponin I below the 99th percentile is associated with higher mortality risk at 2-year follow-up in patients admitted to the ED who did not present with ACS.
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16
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Klingenberg R, Aghlmandi S, Liebetrau C, Räber L, Gencer B, Nanchen D, Carballo D, Akhmedov A, Montecucco F, Zoller S, Brokopp C, Heg D, Jüni P, Marti Soler H, Marques-Vidal PM, Vollenweider P, Dörr O, Rodondi N, Mach F, Windecker S, Landmesser U, von Eckardstein A, Hamm CW, Matter CM, Lüscher TF. Cysteine-rich angiogenic inducer 61 (Cyr61): a novel soluble biomarker of acute myocardial injury improves risk stratification after acute coronary syndromes. Eur Heart J 2018; 38:3493-3502. [PMID: 29155984 DOI: 10.1093/eurheartj/ehx640] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/19/2017] [Indexed: 12/20/2022] Open
Abstract
Aims We aimed to identify a novel biomarker involved in the early events leading to an acute coronary syndrome (ACS) and evaluate its role in diagnosis and risk stratification. Methods and results Biomarker identification was based on gene expression profiling. In coronary thrombi of ACS patients, cysteine-rich angiogenic inducer 61 (Cyr61, CCN1) gene transcripts were highly up-regulated compared with peripheral mononuclear cells. In a murine ischaemia-reperfusion model (I/R), myocardial Cyr61 expression was markedly increased compared with the controls. Cyr61 levels were determined in human serum using an enzyme-linked immunosorbent assay. Cohorts of ACS (n = 2168) referred for coronary angiography, stable coronary artery disease (CAD) (n = 53), and hypertrophic obstructive cardiomyopathy (HOCM) patients (n = 15) served to identify and evaluate the diagnostic and prognostic performance of the biomarker. Cyr61 was markedly elevated in ST-elevation myocardial infarction patients compared with non-ST-elevation myocardial infarction/unstable angina or stable CAD patients, irrespective of whether coronary thrombi were present. Cyr61 was rapidly released after occlusion of a septal branch in HOCM patients undergoing transcoronary ablation of septal hypertrophy. Cyr61 improved risk stratification for all-cause mortality when added to the reference GRACE risk score at 30 days (C-statistic 0.88 to 0.89, P = 0.001) and 1 year (C-statistic 0.77 to 0.80, P < 0.001) comparable to high-sensitivity troponin T (30 days: 0.88 to 0.89, P < 0.001; 1 year: 0.77 to 0.79, P < 0.001). Similar results were obtained for the composite endpoint of all-cause mortality or myocardial infarction. Conversely, in a population-based case-control cohort (n = 362), Cyr61 was not associated with adverse outcome. Conclusion Cyr61 is a novel early biomarker reflecting myocardial injury that improves risk stratification in ACS patients.
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Affiliation(s)
- Roland Klingenberg
- Department of Cardiology, University Heart Center, University Hospital of Zurich and Center for Molecular Cardiology, University of Zurich, Rämistr. 100, CH-8091 Zurich, Switzerland and Wagistr. 12, CH-8952 Schlieren, Switzerland.,Department of Cardiology, Kerckhoff Heart and Thorax Center, Kerckhoff-Klinik, Benekestr. 2-8, D-61231 Bad Nauheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Benekestr. 2-8, D-61231 Bad Nauheim, Germany
| | - Soheila Aghlmandi
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland.,CTU Bern, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland.,Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Spitalstr. 12, CH-4056 Basel, Switzerland
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Kerckhoff-Klinik, Benekestr. 2-8, D-61231 Bad Nauheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Benekestr. 2-8, D-61231 Bad Nauheim, Germany
| | - Lorenz Räber
- Department of Cardiology, Cardiovascular Center, University Hospital of Bern, Freiburgstr. 18, CH-3010 Bern, Switzerland
| | - Baris Gencer
- Department of Cardiology, Cardiovascular Center, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva 14, Switzerland
| | - David Nanchen
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Rue du Bugnon 44, CH-1011 Lausanne, Switzerland
| | - David Carballo
- Department of Cardiology, Cardiovascular Center, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva 14, Switzerland
| | - Alexander Akhmedov
- Department of Cardiology, University Heart Center, University Hospital of Zurich and Center for Molecular Cardiology, University of Zurich, Rämistr. 100, CH-8091 Zurich, Switzerland and Wagistr. 12, CH-8952 Schlieren, Switzerland
| | - Fabrizio Montecucco
- Department of Cardiology, Cardiovascular Center, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva 14, Switzerland.,First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6, Viale Benedetto XV, IT-16132 Genoa, Italy
| | - Stefan Zoller
- Bioinformatics, Genetic Diversity Center, Federal Institute of Technology (ETH), Universitätsstr. 16, CH-8092 Zurich, Switzerland
| | - Chad Brokopp
- Department of Cardiothoracic Surgery, Regenerative Medicine Center, Department of Cardiothoracic Surgery, University Hospital of Zurich, Wagistr. 12, CH-8952 Schlieren, Switzerland
| | - Dik Heg
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland.,CTU Bern, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, 209 Victoria St, Toronto, ON M5B 1T8, Canada
| | - Helena Marti Soler
- Department of General Internal Medicine, University Hospital of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Pedro-Manuel Marques-Vidal
- Department of General Internal Medicine, University Hospital of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Peter Vollenweider
- Department of General Internal Medicine, University Hospital of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
| | - Oliver Dörr
- Department of Cardiology, University Hospital of Giessen, Klinikstr. 33; D-35392 Giessen, Germany
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Gesellschaftsstr. 49, CH-3012 Bern, Switzerland.,Department of General Internal Medicine, University Hospital of Bern, Freiburgstr. 18, CH-3010 Bern, Switzerland
| | - François Mach
- Department of Cardiology, Cardiovascular Center, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva 14, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Cardiovascular Center, University Hospital of Bern, Freiburgstr. 18, CH-3010 Bern, Switzerland
| | - Ulf Landmesser
- Department of Cardiology, University Heart Center, University Hospital of Zurich and Center for Molecular Cardiology, University of Zurich, Rämistr. 100, CH-8091 Zurich, Switzerland and Wagistr. 12, CH-8952 Schlieren, Switzerland.,Department of Cardiology, Charité Campus Benjamin-Franklin, Hindenburgdamm 30, D-12200 Berlin, Germany
| | - Arnold von Eckardstein
- Institute of Clinical Chemistry, University Hospital of Zurich, Rämistr. 100, CH-8091 Zurich, Switzerland
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Kerckhoff-Klinik, Benekestr. 2-8, D-61231 Bad Nauheim, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Benekestr. 2-8, D-61231 Bad Nauheim, Germany.,Department of Cardiology, University Hospital of Giessen, Klinikstr. 33; D-35392 Giessen, Germany
| | - Christian M Matter
- Department of Cardiology, University Heart Center, University Hospital of Zurich and Center for Molecular Cardiology, University of Zurich, Rämistr. 100, CH-8091 Zurich, Switzerland and Wagistr. 12, CH-8952 Schlieren, Switzerland
| | - Thomas F Lüscher
- Department of Cardiology, University Heart Center, University Hospital of Zurich and Center for Molecular Cardiology, University of Zurich, Rämistr. 100, CH-8091 Zurich, Switzerland and Wagistr. 12, CH-8952 Schlieren, Switzerland
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17
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Riedlinger D, Möckel M, Müller C, Holert F, Searle J, von Recum J, Slagman A. High-sensitivity cardiac troponin T for diagnosis of NSTEMI in the elderly emergency department patient: a clinical cohort study. Biomarkers 2018; 23:551-557. [PMID: 29619842 DOI: 10.1080/1354750x.2018.1460763] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE The aim of this study is to evaluate the impact of age on the diagnostic performance of high-sensitivity troponin T (hsTnT) under routine conditions. MATERIALS AND METHODS Data of 4118 consecutive emergency department (ED) patients who underwent a routine TnT measurement between 11 October 2012 and 30 November 2013 were analysed. Diagnostic accuracy of hsTnT was compared in four age categories (<50, 50-64, 65-74, ≥75 years of age) for different cut-off values. Primary endpoint was a main hospital diagnosis of NSTEMI. RESULTS The median age of the study population (n = 4118) was 61 years (IQR: 45-75 years). NSTEMI was diagnosed in 3.3% (n = 136) of all patients. There were significant differences in hsTnT concentrations between age-groups (p < 0.001) in all patients, but not in NSTEMI patients (p = 0.297). 72.2% of all patients ≥75 years of age (583/808) without NSTEMI had hsTnT concentrations above the 99th percentile of a healthy reference population. Specificity at 14 ng/L was 93.6% (95% CI: 92.12-94.87) in patients below 50 years of age and 27.9% (95% CI: 24.78-31.08) in patients 75 years of age and older. CONCLUSIONS Patients' age needs to be considered at least one influencing factor on hsTnT concentrations at admission and should be included in the clinical interpretation of hsTnT concentrations for further clinical workup beneath other influencing factors like comorbidities and symptom onset time. The implementation of age-specific cut-off values could be considered for single troponin testing at admission but is associated with an increased risk of underdiagnosis of NSTEMI.
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Affiliation(s)
- Dorothee Riedlinger
- a Division of Emergency and Acute Medicine (Campus Virchow Klinikum and Campus Charité Mitte) , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Martin Möckel
- a Division of Emergency and Acute Medicine (Campus Virchow Klinikum and Campus Charité Mitte) , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Christian Müller
- a Division of Emergency and Acute Medicine (Campus Virchow Klinikum and Campus Charité Mitte) , Charité Universitätsmedizin Berlin , Berlin , Germany.,b Department of Laboratory Medicine , Charité - Universitätsmedizin Berlin , Berlin , Germany
| | - Fabian Holert
- a Division of Emergency and Acute Medicine (Campus Virchow Klinikum and Campus Charité Mitte) , Charité Universitätsmedizin Berlin , Berlin , Germany.,b Department of Laboratory Medicine , Charité - Universitätsmedizin Berlin , Berlin , Germany
| | - Julia Searle
- a Division of Emergency and Acute Medicine (Campus Virchow Klinikum and Campus Charité Mitte) , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Johannes von Recum
- a Division of Emergency and Acute Medicine (Campus Virchow Klinikum and Campus Charité Mitte) , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Anna Slagman
- a Division of Emergency and Acute Medicine (Campus Virchow Klinikum and Campus Charité Mitte) , Charité Universitätsmedizin Berlin , Berlin , Germany
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18
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Andruchow JE, Kavsak PA, McRae AD. Contemporary Emergency Department Management of Patients with Chest Pain: A Concise Review and Guide for the High-Sensitivity Troponin Era. Can J Cardiol 2017; 34:98-108. [PMID: 29407013 DOI: 10.1016/j.cjca.2017.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022] Open
Abstract
This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours. In contrast, highly abnormal troponin concentrations on presentation (more than 5 times the upper reference limit) or rapidly rising levels on serial testing can rapidly rule in AMI with high specificity. However, approximately one-third of patients remain in a biomarker-indeterminate "observation zone" even after serial sampling. These patients pose a disposition challenge to clinicians because although the differential diagnosis of elevated troponin concentrations is broad, these patients have an increased risk for short-term major adverse cardiac events. Use of repeated serial troponin sampling and structured clinical prediction tools may assist disposition for these patients, because no validated pathways currently exist to guide clinicians. Ongoing research to tailor diagnostic thresholds to individual patient characteristics may enable improved diagnostic accuracy and usher in a new era of personalized medicine in the evaluation of suspected ACS.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada.
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
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19
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Aakre KM, Kleiven Ø, Skadberg Ø, Bjørkavoll-Bergseth MF, Melberg T, Strand H, Hagve TA, Ørn S. The copeptin response after physical activity is not associated with cardiac biomarkers or asymptomatic coronary artery disease: The North Sea Race Endurance Exercise Study (NEEDED) 2013. Clin Biochem 2017; 52:8-12. [PMID: 29079359 DOI: 10.1016/j.clinbiochem.2017.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/06/2017] [Accepted: 10/13/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Copeptin concentrations increase both during acute coronary syndrome and following physical exercise. The relationship between copeptin increase following physical exercise and coronary artery disease (CAD) is uncertain. The aim of this study was to 1) describe the copeptin response following strenuous physical exercise, and 2) investigate the determinants of exercise induced copeptin concentrations, particularly in relation to cardiac biomarkers and CAD. METHODS Serum samples were collected from 97 recreational cyclists 24h before, and immediately, 3 and 24h after a 91-km bike race. Three subjects were subsequently diagnosed with significant asymptomatic CAD. Delta copeptin concentrations were correlated to patient characteristics and to biomarker concentrations. RESULTS Participants were 42.8±9.6years, and 76.3% were male. Copeptin concentrations increased to maximal levels immediately after the race and were normalized in >90% after 3h. A total of 53% and 39% exceeded the 95th and 99th percentile of the assay (10 and 19pmol/L) respectively. In multivariate models, race time, serum sodium, creatinine and cortisol were significant predictors of copeptin levels. There was no correlation between changes in copeptin and changes in cardiac biomarkers (hs-cTnI, hs-cTnT and BNP). Copeptin concentrations were normal in the subjects with asymptomatic CAD. CONCLUSIONS The moderate, short-term, exercise induced copeptin increase observed in the present study was not related to hs-cTn or BNP levels. Copeptin was normal in three asymptomatic recreational athletes with significant CAD.
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Affiliation(s)
- Kristin M Aakre
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway.
| | - Øyunn Kleiven
- Cardiology Department, Stavanger University Hospital, Stavanger, Norway
| | - Øyvind Skadberg
- Laboratory of Clinical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | - Tor Melberg
- Cardiology Department, Stavanger University Hospital, Stavanger, Norway
| | - Heidi Strand
- Multidisciplinary Laboratory Medicine and Medical Biochemistry, Akershus University Hospital, Lørenskog, Norway
| | - Tor-Arne Hagve
- Multidisciplinary Laboratory Medicine and Medical Biochemistry, Akershus University Hospital, Lørenskog, Norway; Institute of clinical medicine, Akershus University Hospital, University of Oslo, Norway
| | - Stein Ørn
- Cardiology Department, Stavanger University Hospital, Stavanger, Norway; Department of Electrical Engineering and Computer Science, University of Stavanger, Norway
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20
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Bandstein N, Wikman A, Ljung R, Holzmann MJ. Survival and resource utilization in patients with chest pain evaluated with cardiac troponin T compared with high-sensitivity cardiac troponin T. Int J Cardiol 2017; 245:43-48. [DOI: 10.1016/j.ijcard.2017.05.111] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/14/2017] [Accepted: 05/29/2017] [Indexed: 10/18/2022]
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21
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Sandoval Y, Smith SW, Love SA, Sexter A, Schulz K, Apple FS. Single High-Sensitivity Cardiac Troponin I to Rule Out Acute Myocardial Infarction. Am J Med 2017; 130:1076-1083.e1. [PMID: 28344141 DOI: 10.1016/j.amjmed.2017.02.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study examined the performance of single high-sensitivity cardiac troponin I (hs-cTnI) measurement strategies to rule out acute myocardial infarction. METHODS This was a prospective, observational study of consecutive patients presenting to the emergency department (n = 1631) in whom cTnI measurements were obtained using an investigational hs-cTnI assay. The goals of the study were to determine 1) negative predictive value (NPV) and sensitivity for the diagnosis of acute myocardial infarction, type 1 myocardial infarction, and type 2 myocardial infarction; and 2) safety outcome of acute myocardial infarction or cardiac death at 30 days using hs-cTnI less than the limit of detection (LoD) (<1.9 ng/L) or the High-STEACS threshold (<5 ng/L) alone and in combination with normal electrocardiogram (ECG). RESULTS Acute myocardial infarction occurred in 170 patients (10.4%), including 68 (4.2%) type 1 myocardial infarction and 102 (6.3%) type 2 myocardial infarction. For hs-cTnI<LoD (27%), the NPV and sensitivity for acute myocardial infarction were 99.6% (95% confidence interval 98.9%-100%) and 98.8 (97.2%-100%). For hs-cTnI<5 ng/L (50%), the NPV and sensitivity for acute myocardial infarction were 98.9% (98.2%-99.6%) and 94.7% (91.3%-98.1%). In combination with a normal ECG, 1) hs-cTnI<LoD had an NPV of 99.6% (98.9%-100%) and sensitivity of 99.4% (98.3%-100%); and 2) hs-cTnI<5 ng/L had an NPV of 99.5% (98.8%-100%) and sensitivity of 98.8% (97.2%-100%). The NPV and sensitivity for the safety outcome were excellent for hs-cTnI<LoD alone or in combination with a normal ECG, and for hs-cTnI<5 ng/L in combination with a normal ECG. CONCLUSION Strategies using a single hs-cTnI alone or in combination with a normal ECG allow the immediate identification of patients unlikely to have acute myocardial infarction and who are at very low risk for adverse events at 30 days.
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Affiliation(s)
- Yader Sandoval
- Division of Cardiology, Hennepin County Medical Center and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minn
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Sara A Love
- Minneapolis Medical Research Foundation, Minn; Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis
| | - Anne Sexter
- Minneapolis Medical Research Foundation, Minn
| | | | - Fred S Apple
- Minneapolis Medical Research Foundation, Minn; Department of Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota, Minneapolis.
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22
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Abstract
Patients presenting with acute chest pain are a challenge for attending physicians in private practice and specialists for emergency and acute medicine in hospitals because a wide spectrum of diagnoses may be the cause, ranging from acute myocardial infarction (AMI) to harmless muscular tension. The evaluation of patients with acute chest pain follows basic principles independent of the setting: A thorough clinical investigation by the responsible physician including medical history and physical examination, followed by a 12-channel electrocardiogram (ECG) and further focused diagnostics. The decision about hospital admission, monitoring and further diagnostic steps depends on the estimation of vital risk, the tentative diagnosis and the available diagnostic tools. Besides the ECG, laboratory tests (cardiac troponin, copeptin) and cardiac imaging (primarily the echocardiography) play a key role. Patients who did not necessarily require hospital admission (e. g. after exclusion of AMI) should be offered an inpatient or outpatient concept which enables the timely diagnosis and potential treatment of all relevant diseases in question. The diagnostic strategies need to take into account the pretest probability and for patients with confirmed diagnosis of an acute coronary syndrome (ACS), continuous monitoring and transfer to an emergency department with integrated chest pain unit (CPU) is strongly recommended. In this context, close collaboration between the emergency department and the physicians in private practice should be established.
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Affiliation(s)
- M Möckel
- Arbeitsbereich Notfallmedizin/Rettungsstellen/CPU, Campus Virchow-Klinikum und Charité Mitte, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13363, Berlin, Deutschland.
| | - T Störk
- CardioPraxis Staufen, Göppingen, Deutschland.,Kardiologie, Klinik für Innere Medizin II, Universitätsklinikum Ulm, Ulm, Deutschland
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23
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Möckel M, Slagman A, Searle J. Biomarker strategies: the diagnostic and management process of patients with suspected AMI. Diagnosis (Berl) 2016. [PMID: 29536898 DOI: 10.1515/dx-2016-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Security standards of our times largely exclude a discharge of patients with chest pain from the emergency departments (EDs) based on clinical assessment alone. Given the increasing use and consequently crowding of EDs worldwide and the large proportion of patients who present to the EDs with, however vague, signs and symptoms of acute coronary syndrome, there is a strong clinical and public health need to achieve a faster but safe rule-in and rule-out of acute myocardial infarction (AMI) to direct patients onto the correct management pathway. A number of approaches for a faster rule-in and rule-out of AMI are currently under research and evaluation and some have already been integrated into current guidelines and/or implemented into the clinical routine in selected centers. This article summarizes these different diagnostic strategies for patients with suspected AMI, using cardiac troponin alone or in combination with copeptin.
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Affiliation(s)
- Martin Möckel
- 1Division of Emergency Medicine/Chest Pain Units, Campus Virchow Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Slagman
- 1Division of Emergency Medicine/Chest Pain Units, Campus Virchow Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Searle
- 1Division of Emergency Medicine/Chest Pain Units, Campus Virchow Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
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24
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Mueller C, Patrono C, Roffi M. Background, fundamental concepts, and scientific evidence of the high-sensitivity cardiac troponin 0h/1h-algorithm for early rule-out or rule-in of acute myocardial infarction. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw282.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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25
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Crea F, Jaffe AS, Collinson PO, Hamm CW, Lindahl B, Mills NL, Thygesen K, Mueller C, Patrono C, Roffi M. Should the 1h algorithm for rule in and rule out of acute myocardial infarction be used universally? Eur Heart J 2016; 37:3316-3323. [PMID: 28007934 DOI: 10.1093/eurheartj/ehw282] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Affiliation(s)
| | | | | | | | - Bertil Lindahl
- Uppsala University and Uppsala Clinical Research Center, Uppsala University, Sweden
| | | | | | - Christian Mueller
- Department of Cardiology and the Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Carlo Patrono
- Istituto di Farmacologia, Università Cattolica del Sacro Cuore, Largo F. Vito 1, IT-00168 Rome, Italy
| | - Marco Roffi
- Division of Cardiology, University Hospital, Rue Gabrielle Perret-Gentil 4, 1211 Geneva, Switzerland
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26
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Morici N, Farioli L, Losappio LM, Colombo G, Nichelatti M, Preziosi D, Micarelli G, Oliva F, Giannattasio C, Klugmann S, Pastorello EA. Mast cells and acute coronary syndromes: relationship between serum tryptase, clinical outcome and severity of coronary artery disease. Open Heart 2016; 3:e000472. [PMID: 27752333 PMCID: PMC5051537 DOI: 10.1136/openhrt-2016-000472] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/10/2016] [Accepted: 08/16/2016] [Indexed: 01/14/2023] Open
Abstract
Objective To assess the relationship between serum tryptase and the occurrence of major cardiovascular and cerebrovascular events (MACCE) at 2-year follow-up in patients admitted with acute coronary syndrome (ACS). To compare serum tryptase to other validated prognostic markers (maximum high-sensitivity troponin (hs-Tn), C reactive protein (CRP) levels at admission, Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) score). Methods We measured serum tryptase at admission in 140 consecutive patients with ACS and in 50 healthy controls. The patients’ follow-up was maintained for 2 years after discharge. The predictive accuracy of serum tryptase for 2-year MACCE was assessed and compared with hs-Tn, CRP and SYNTAX score. Results Serum tryptase levels at admission were significantly higher in patients with ACS compared with the control group (p=0.0351). 2 years after discharge, 28/140 patients (20%) experienced MACCE. Serum tryptase levels, maximum hs-Tn measurements and SYNTAX score were higher in patients who experienced MACCE compared with those without (p<0.0001). Conversely, we found no significant association between MACCE and CRP. The predictive accuracy of serum tryptase for MACCE was set at the cut-off point of 6.7 ng/mL (sensitivity 46%, specificity 84%). Conclusions In patients with ACS, serum tryptase measured during index admission is significantly correlated to the development of MACCE up to 2 years, demonstrating a possible long-term prognostic role of this biomarker.
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Affiliation(s)
- Nuccia Morici
- Dipartimento Cardiotoracovascolare , SS UTIC/ SC Cardiologia 1-Emodinamica, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
| | - Laura Farioli
- Department of Laboratory Medicine , ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
| | - Laura Michelina Losappio
- Department of Allergology and Immunology , ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
| | - Giulia Colombo
- Medicine Department , Milano-Bicocca University , Milan , Italy
| | - Michele Nichelatti
- Service of Biostatistics, Department of Hematology , ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
| | - Donatella Preziosi
- Department of Allergology and Immunology , ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
| | - Gianluigi Micarelli
- Department of Allergology and Immunology , ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
| | - Fabrizio Oliva
- Dipartimento Cardiotoracovascolare , SS UTIC/ SC Cardiologia 1-Emodinamica, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
| | - Cristina Giannattasio
- Medicine Department, Milano-Bicocca University, Milan, Italy; Cardiology IV, A. De Gasperis Department, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda, Milan, Italy
| | - Silvio Klugmann
- Dipartimento Cardiotoracovascolare , SS UTIC/ SC Cardiologia 1-Emodinamica, ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
| | - Elide Anna Pastorello
- Department of Allergology and Immunology , ASST Grande Ospedale Metropolitano Niguarda Ca' Granda , Milano , Italy
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27
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Fox WR, Diercks DB. Troponin assay use in the emergency department for management of patients with potential acute coronary syndrome: current use and future directions. Clin Exp Emerg Med 2016; 3:1-8. [PMID: 27752608 PMCID: PMC5051615 DOI: 10.15441/ceem.16.120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/05/2016] [Accepted: 02/05/2016] [Indexed: 01/01/2023] Open
Abstract
Troponins are proteins commonly found in cardiac tissue that are released during myocardial ischemia or necrosis. These troponins can be detected by assays that can then be used to guide clinical decision-making and disposition, especially if the suspected insult is related to acute coronary syndrome. Timing of troponin measurement can be important as elevations may not be detectible immediately after an insult. New assays have been designed to detect troponin con-centrations previously too low to be detected by conventional assays. These tests are known as high-sensitivity cardiac troponin assays. Current research is aimed at evaluating the clinical sig-nificance of troponin elevations detected by these new assays especially in management of pa-tients with suspected acute coronary syndrome. A number of risk-stratification scores exist to assist physicians with evaluating chest pain in the emergency department in the context of de-tection (or absence) of troponins in systemic circulation. Additionally, investigators are working to integrate data generated by hs-cTn measurements into existing and new risk-stratification scores.
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Affiliation(s)
- William R Fox
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX , USA
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX , USA
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